Estimated Hospital Charges

Reimbursement to the hospital (and the patients financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2014 charge estimates are based on historical patient visits in 2012, including Mental Health and Substance Abuse services. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

Other Local Destruction of Lesion or Tissue of Skin/Subcutaneous Tissue

$1,542

$771

Other Transurethral Excision or Destruction of Lesion or Tissue of Bladder

$8,598

$4,299

Ureteral Catheterization

$11,109

$5,555

Other Miscellaneous Outpatient Services

Cat Scan (CT) of the Abdomen and Pelvis w/out Contrast

$2,562

$1,281

Cat Scan (CT) of the Head w/out Contrast

$1,110

$555

Chest X-Ray (PA & Lateral)

$265

$133

Digital Mammography (Mammogram) Screening

$280

$140

Emergency Room (includes physician fee)*

Procedure

Charges*

Uninsured Self Pay Charge*

Level 1 (least critical)

$168

$84

Level 2

$261

$131

Level 3

$540

$270

Level 4

$940

$470

Level 5 (most critical)

$1,629

$815

*Charges shown are for basic facility and professional fees and do not include any additional services that may be performed in the Emergency Department.

The above 2014 charge estimates are based on rates as of 01/01/2013. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

Provider Based Primary Care Physician Practices

Procedure

Insured and Uninsured Charges**

99201

New Patient Level 1

$79

99202

New Patient Level 2

$136

99203

New Patient Level 3

$195

99204

New Patient Level 4

$302

99205

New Patient Level 5

$380

99211

Established Patient Level 1

$39

99212

Established Patient Level 2

$78

99213

Established Patient Level 3

$132

99214

Established Patient Level 4

$197

99215

Established Patient Level 5

$266

99241

Primary Care Physician Consult Level 1

$147

99242

Primary Care Physician Consult Level 2

$233

99243

Primary Care Physician Consult Level 3

$302

99244

Primary Care Physician Consult Level 4

$424

99245

Primary Care Physician Consult Level 5

$571

**Charges shown are for basic facility and professional fees and do not include any additional services that may be performed in the facility, practice or in any other non primary care physician practice.

The above 2014 charge estimates are based on rates as of 01/01/2013. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.